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San Joaquin Coun k <br />HIT$.'yEnvironmental,.H'eaith',,D,' art' tP, IvM<. <br />604 East alri:Street, Stockton, CA'95202-3029 �a IAON - <br />{209} 4b8 3449- ,(209) 468=3433 Web www sjgov.org/ehd ' <br />q ORQN��L�-TH <br />Weld P.ennit-Appwb6tlon: ' <br />f , <br />TM NON=REFUNDABLE PERMIT EXPIRES 7 YEAR FROIIR DATE i83UEl] <br />- . <br />Applicatlon;is hereby merle to Ssn Joaquin County or a perm to construct and/or;lnstail the"uwilc`de5cxibed.. This appitcallon Iwniade in compllanne with San W <br />Joage�n Comity Developrrment Title Chapter 9-1115.3 and the'Standards:of San Joaquin County Ernrlronmer6l Hea1t), Department >, <br />i TRACY c 95376 Ms essors' 233n1-30.-2,? <br />WEt:L LOCBtIOn}95 WEST 11tH STREET;-' '; C:rOSS $treat S' Clty , - zip '-a'arCel <br />PROPERTY k ` a ,r.` Tracy ; 95376 9251 743 9023 T. <br />95 West 11th Street' <br />Ovuner Joseph Panetta .: Address CII^Zip Phone# +. <br />d <br />...ALL WELL ABRNbONNENT" - BEAGLE Basan - a ey -R Placerville.95667 ::#1849359 i- 1 800' 948-1355 <br />C-57 Contractor, x Address City U4 ... Phone# <br />r A"G->~.;, 837 Shaw;Rd: StocktonUS Phan 209 4671006 <br />Conauttant l Sub Crltr Address _ .. Clry .- - - <br />(i!$Coordinates. X Y . ��.�• ToVunshlp _ Raflge 5e6llon� <br />WORK TO BE PERFORMEi?, x K� <br />NEW WEL LI BORING (Cpl, GEOPROBE, HYDRO' -JCH, HAND AUGER OTHER*) {j DESTRUCTION (choose type below) <br />O SOIL BORING # 3 :. OVER=BORE ,-DIAMETERe 5 inch <br />SSURE <br />A WEiL # GROUT "` 9 1 a j j PR - <br />j 1 EPgrtland (Type <br />ROUT SPECIFICATIONS <br />COMMENTS 'Monitoring Well Destruction Work Plan 25 `3anua{ry' 2010 �- Per SJ Co Cade <br />3M. <br />TYPE OF WE4 k LI�ST}IL66MON TYPE C UC " G I C �8 25 inch x <br />8`25 a two inch <br />MONITORING V HOLLOW STENT DIA OF BOREHOLES B MULTIPLE;CASINGI- MULTI-LEVEL .WELL CASING DIA': <br />'EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS i�4 `•TYPE OF CASING. a STEEL"' a OTHER <br />(]VAPOR [j MUD ROTARY DEPTH OF GROUT SEAL 23 ' and :35' TREMI(r TYPE TO BE USED::')n .UGERS 0-HOS E <br />B AIR SPARGE! OZONE U PUSH POINT (GP of CPT)GROUT SEAL PUMPED;. 0 Yes Q No (NOTE. MAXIMUM FREE -FALL DEPTH IS 30') <br />aSOIL BORING .d HAND AUGER GROUTSPECIFICATIONS Pd' tlanti--(Type;tI) <br />' <br />� OTHER: d OTHER. - ._,...... APPROX. BORING D 26' and 35 <br />EPTH ff BOLTED TRAFFIC BOX or O STOVE PEPE <br />i' CONDUCTOR CASINO PROPOSED_ -• Nc . (if YES, list specifications in comment' section) <br />COMMENTS: .Monitoring Wella: MW 5'(15'), MW 9(20!) MW -7(201), MW -13(35'), NW412(20') <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT_ PERMITS .- <br />48 WORKING HOURS NOTICE REQUIRED rFOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the v 6r will be done In accordance with Sad -Joaquin <br />County Ordinances, Rules and Regulations, and all applicable Caiifornli State Laws. <br />Signed x �+ i[. <br />�`�']�y Project-Manager/A.G.E. <br />W ��t _.TtielGompany <br />Print Name William Little' 26 January 2010 <br />Data <br />DEPARTMENT LISE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:._ - • - . <br />WORK PLAN DATED: <br />Appllcation,Accepted 6 Date Issued Area <br />Grout inspection By. -`4 - _ _ - e -Final insp on By <br />c <br />l)estruction.lns action B w <br />ACCOUNTING'ONLY: AIDiI <br />FACl2' - - - <br />PE CODES FEE INFO AMOUNT REMITTED HECK #' REC'D 13Y' WE- " PEtiIlAIT f SERVICE REQUEST A- s _ INVOICE <br />SR# x <br />s <br />C-57 WC_ -WAIVER_ C-57 Letter of Authorization to sign permit --.1Z Enweetelsttte►rt-fl7c �✓ <br />PH 29-02-001 ',WEB <br />9/1112007 , <br />